加速康复外科理念下的营养管理在围手术期脊柱结核患者中的价值

doi:10.19982/j.issn.1000-6621.20220052

摘要/Abstract

摘要：

目的: 探讨加速康复外科(enhanced recovery after surgery, ERAS)理念下的营养管理在围手术期脊柱结核患者中的价值。 方法: 收集2021年1—12月于北京胸科医院骨科住院并接受手术治疗的脊柱结核患者79例,采用随机数字表法将患者随机分为观察组(42例)和对照组(37例),观察组2例患者中途退出试验,最终纳入40例。观察组患者采用ERAS理念下的围手术期营养管理,对照组采用常规手术管理。比较两组患者在入院时、术后第6天及第13天营养风险发生情况,两组患者在入院时、术后第1天、第6天及第13天血清学化验指标的差异,以及两组在术中出血量、术后引流量、拔管时间、术后排气时间、排便时间等临床结局间的差异。 结果: 术后第6天、第13天观察组营养风险发生率分别为70.0%(28/40)、57.1%(20/35),均低于对照组[94.6%(35/37)、81.8%(27/33)],差异均有统计学意义(χ²值分别为7.816和4.845,P值分别为0.005和0.028)。观察组患者术后第1天白细胞计数平均值为(9.99±3.12)×10⁹/L,低于对照组[(11.69±2.74)×10⁹/L],差异有统计学意义(t=2.529,P=0.014)。术后第6天观察组患者白蛋白平均水平为(33.48±4.47)g/L,高于对照组[(31.35±3.51)g/L],差异有统计学意义(t=-2.310,P=0.024)。观察组术后第1天尿酸平均水平为(274.67±116.91)μmol/L,低于对照组[(339.19±115.79)μmol/L],差异有统计学意义(t=2.416,P=0.018)。观察组患者术中中位出血量为 300.0(175.0,500.0)ml,少于对照组患者[400.0(250.0,600.0)ml],差异有统计学意义(Z=2.098,P=0.036);观察组术后中位排气时间为25.5(15.5,37.5)h、平均排便时间为(95.7±46.9)h,对照组术后中位排气时间为30.7(21.5,44.5)h、平均排便时间为(117.3±38.8)h,差异均有统计学意义(Z=2.050,P=0.040;t=2.140,P=0.036)。 结论: ERAS理念下的营养管理可有效改善脊柱结核患者术后营养状况,促进术后胃肠道功能恢复,利于患者加速康复。

关键词: 结核,脊柱, 康复, 营养支持

Abstract:

Objective: To explore the value of nutrition management under the concept of enhanced recovery after surgery (ERAS) in perioperative patients with spinal tuberculosis. Methods: A total of 79 patients with spinal tuberculosis who were hospitalized and operated in the Department of Orthopaedics in the Beijing Chest Hospital during January to December 2021 were chosen and were randomly allocated into observation group (42 cases) and control group (37 cases) using random number table. Two cases in the observation group withdrew from the experiment halfway which left the group with 40 patients finally. Patients in the observation group were given perioperative nutrition management under ERAS concept, while those in the control group were given routine operation management. The nutritional risks of these two groups were observed at the time of admission, the 6th and 13th day after operation. Differences of serological test results at admission, the 1st, 6th and 13th day after operation were compared, as well as the differences of intraoperative and postoperative blood loss, drainage, extubation time, time of first gas and defecation. Results: On the 6th and 13th day after operation, among the observation group,70.0% (28/40) and 57.1% (20/35) had nutritional risk, which were lower than that in the control group (94.6% (35/37) and 81.8% (27/33), χ²=7.816, P=0.005; χ²=4.845,P=0.028). On the 1st day after operation, the average amount of WBC among the observation group was (9.99±3.12)×10⁹/L, which was lower than that of the control group ((11.69±2.74) ×10⁹/L, t=2.529, P=0.014). On the 6th day after operation, the average blood albumin in the observation group was (33.48±4.47)g/L, which was higher than that in the control group ((31.35±3.51)g/L, t=-2.310,P=0.024).The average uric acid level of the observation group was (274.67±116.91)μmol/L, lower than that in the control group ((339.19±115.79)μmol/L, t=2.416,P=0.018). The median (IQR) blood loss during operation in the observation group was 300.0 (175.0,500.0) ml, which was less than that in the control group (400.0 (250.0,600.0) ml, Z=2.098,P=0.036). Median (IQR) postoperative exhaust time and average defecation time in the observation group were 25.5 (15.5,37.5)h and (95.7±46.9)h, both of which were shorter than that in the control group (30.7 (21.5,44.5)h, (117.3±38.8)h, Z=2.050,P=0.040;t=2.140,P=0.036). Conclusion: The nutrition management under ERAS concept can effectively improve the nutritional status of patients with spinal tuberculosis and promote the recovery of gastrointestinal function thus help patients recover quickly.

Key words: Tuberculosis,spinal, Rehabilitation, Nutritional support

中图分类号:

R529.2

陈洋, 李卓, 焦媚, 马皎洁. 加速康复外科理念下的营养管理在围手术期脊柱结核患者中的价值[J]. 中国防痨杂志, 2022, 44(6): 549-554. doi: 10.19982/j.issn.1000-6621.20220052

CHEN Yang, LI Zhuo, JIAO Mei, MA Jiao-jie. Value of nutrition management under the concept of enhanced recovery after surgery in perioperative patients with spinal tuberculosis[J]. Chinese Journal of Antituberculosis, 2022, 44(6): 549-554. doi: 10.19982/j.issn.1000-6621.20220052

图/表 5

表1

两组患者的一般特征比较

特征	观察组(40例)	对照组(37例)	统计检验值	P值
性别[例(构成比,%)]			χ²=2.274	0.132
男性	18(45.0)	23(62.2)
女性	22(55.0)	14(37.8)
年龄(岁, $x ¯$ ±s)	38.48±12.75	43.78±12.58	t=1.837	0.070
体质量(kg, $x ¯$ ±s)	62.39±9.24	65.11±11.35	t=1.157	0.251
体质量指数( $x ¯$ ±s)	22.73±2.93	22.88±3.34	t=0.221	0.826
合并肺结核[例(发生率,%)]			χ²=0.830	0.362
是	17(42.5)	12(32.4)
否	23(57.5)	25(67.6)
合并其他基础疾病[例(发生率,%)]			χ²=2.092	0.148
是	11(27.5)	16(43.2)
否	29(72.5)	21(56.8)

表1

表2

表3

表4

两组患者不同时间营养相关指标的比较

组别		WBC (×10⁹/L, $x ¯$ ±s)		HGB (g/L, $x ¯$ ±s)		ALB (g/L, $x ¯$ ±s)		GLU (mmol/L, $x ¯$ ±s)		UA (μmol/L, $x ¯$ ±s)
入院次日
观察组		5.88±1.98		122.68±18.97		39.97±4.83		4.86±0.59		486.25±197.80
对照组		6.46±2.30		125.14±16.83		39.00±2.87		4.92±0.76		559.91±192.45
统计检验值		t=1.187		t=0.600		t=-1.065		t=0.379		t=1.654
P值		0.239		0.550		0.290		0.706		0.102
术后第1天
观察组		9.99±3.12		104.03±14.82		32.97±3.79		5.95±1.32		274.67±116.91
对照组		11.69±2.74		104.89±16.18		32.14±3.64		6.00±1.18		339.19±115.79
统计检验值		t=2.529		t=0.245		t=-0.977		t=0.179		t=2.416
P值		0.014		0.807		0.332		0.859		0.018
术后第6天
观察组		6.31±2.33		99.50±15.10		33.48±4.47		5.14±0.86		300.40±137.33
对照组		7.30±2.61		96.86±15.45		31.35±3.51		5.13±0.92		329.74±121.70
统计检验值		t=1.765		t=-0.756		t=-2.310		t=-0.013		t=0.989
P值		0.082		0.452		0.024		0.990		0.326
组别	WBC (×10⁹/L, $x ¯$ ±s)		HGB (g/L, $x ¯$ ±s)		ALB (g/L, $x ¯$ ±s)		GLU (mmol/L, $x ¯$ ±s)		UA (μmol/L, $x ¯$ ±s)
术后13天
观察组	6.28±2.31		104.45±15.02		35.71±3.77		4.96±0.65		369.30[248.20,560.10]^a
对照组	7.32±2.14		102.52±17.08		34.61±3.75		5.23±1.21		458.80[296.50,593.90]^a
统计检验值	t=1.838		t=-0.474		t=-1.158		t=1.097		Z=-0.832
P值	0.071		0.637		0.252		0.277		0.406

表4

表5

两组患者临床相关指标的比较

组别	术中出血量 [ml,M(Q₁,Q₃)]	引流量 [ml,M(Q₁,Q₃)]	拔管时间 [d,M(Q₁,Q₃)]	排气时间 [h,M(Q₁,Q₃)]	排便时间 (h, $x ¯$ ±s)	住院天数 [d,M(Q₁,Q₃)]	住院费用 (万元, $x ¯$ ±s)
观察组	300.0 (175.0,500.0)	580.0 (376.0,917.5)	7.0 (6.0,9.0)	25.5 (15.5,37.5)	95.7±46.9	25.0 (22.0,29.0)	11.3±2.3
对照组	400.0 (250.0,600.0)	730.0 (490.0,1080.0)	7.0 (6.0,9.0)	30.7 (21.5,44.5)	117.3±38.8	24.0 (21.0,31.0)	12.0±3.3
统计检验值	Z=2.098	Z=1.402	Z=-0.672	Z=2.050	t=2.140	Z=-0.414	t=1.100
P值	0.036	0.161	0.501	0.040	0.036	0.679	0.274

表5

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时间分组	围手术期营养管理方式
入院次日	营养风险筛查与评估:应用NRS2002评分对入组患者进行营养风险筛查,依据筛查结果,≥3分者给予营养支持,<3分者1周后再评估
入院次日至术前1日
观察组	无营养风险者给予高蛋白饮食、低营养风险和轻度营养不良者每日口服400~600kcal营养补充进行干预,重度营养不良患者至少干预7d后再考虑手术
对照组	无营养风险者不予干预,存在营养风险者依据能量摄入及营养状况给予相应均衡型能量营养素补充
术前1日
观察组	禁食6h,禁水2h,术前10h给予含糖饮品400~800ml,术前2h给予含糖饮品200~400ml
对照组	禁食8h,禁水4h
术后当天
观察组	麻醉清醒后给予清水20ml,术后4h给予清水50ml+10g合生元,术后6h给予全营养制剂1袋,后恢复饮食
对照组	待排气后开始进水,饮食从流质饮食逐步过渡至正常饮食
术后次日至3日
观察组	给予患者每日2次合生元,10g/次
对照组	无特殊干预
时间分组	围手术期营养管理方式
术后次日至7日
观察组	在基本饮食基础上给予每日口服结核病患者专用全营养补充制剂3次,每次50g
对照组	基本饮食,依据营养风险状况给予相应均衡型肠内营养补充制剂
术后至出院
观察组和对照组	定期随诊、动态评估营养状况,给予个性化营养支持

组别	入院时 [例(发生率,%)]	术后第6天 [例(发生率,%)]	术后第13天 [例(发生率,%)]^a
观察组(40例)	20(50.0)	28(70.0)	20(57.1)
对照组(37例)	15(40.5)	35(94.6)	27(81.8)
χ²值	0.694	7.816	4.845
P值	0.405	0.005	0.028